Emergency Medical Minute

Author: Rachel Beham, PharmD Educational Pearls: Tenecteplase is more specific for fibrin and has a longer half-life than alteplase. In setting of ischemic stroke, tenecteplase before thrombectomy was associated with a statistically higher incidence of reperfusion and better functional outcome than alteplase. References Bruce C.V. Campbell B et al (2018). Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. New England Journal of Medicine. 378:1573-1582

Author: Chris Holmes, MD Educational Pearls: Epidemiology: 80% male, ages 1-4 at greatest risk, African-American > Caucasian. Freshwater and ocean water may have more bacteria than pool water. Salt water is hyperosmolar, which theoretically increases risk of pulmonary edema. Greatest physiologic insult is from hypoxia secondary to fluid aspiration or laryngeal spasm. Patient survival is related to presentation on arrival. Workup includes CXR and ABG; consider C-spine immobilization/imaging when cervical injury is strongly suspected (i.e. diving injury). Treatment consists of supplemental oxygen therapy. Consider CPAP or intubation. References Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012. 366(22):2102-10. doi: 10.1056/NEJMra1013317. Schmidt A, Sempsrott J. Drowning In The Adult Population: Emergency Department Resuscitation And Treatment. Emerg Med Pract. 2015. 17(5):1-18.

Author: Jared Scott, MD Educational Pearls: Data is mixed, but some studies show 1-2% of pregnancies are ectopic. Risk factors for ectopic pregnancies include: pelvic inflammatory disease, prior ectopic pregnancy, prior abdominal surgery, prior abortion, advanced maternal age, IUD, tubal blockage, and smoking (including spouse). Greatest risk factor is a prior ectopic pregnancy, which carries a 17x higher risk. Patients with histories of PID and cigarette smoking present educational opportunities. References Moini, A., Hosseini, R., Jahangiri, N., Shiva, M., & Akhoond, M. R. (2014). Risk factors for ectopic pregnancy: A case–control study. Journal of Research in Medical Sciences : The Official Journal of Isfahan University of Medical Sciences, 19(9), 844–849. Rana, P; Kazmi, I; Singh, R; Afzal, M; Al-Abbasi, FA; Aseeri, A; Singh, R; Khan, R; Anwar, F (2013). "Ectopic pregnancy: a review". Archives of Gynecology and Obstetrics. 288 (4): 747–57. doi: 10.1007/s00404-013-2929-2.

Author: Chris Holmes, MD Educational Pearls: Symptoms commonly seen with mononucleosis are palatal petechiae, posterior cervical lymphadenopathy, inguinal/axillary lymphadenopathy, splenomegaly, and/or atypical lymphocytes > 10% on CBC. Among these, posterior cervical lymphadenopathy and atypical lymphocytes > 10% were the most sensitive (sensitivities of 0.64 and 0.66 respectively). References Welch, JL et al. What Elements Suggest Infectious Mononucleosis? Annals of Emergency Medicine. 2018. 71(4): 521-522. Doi: 10.1016/j.annemergmed.2017.06.014

Author: John Winkler, MD Educational Pearls: Singed nasal hairs, soot around mouth, hoarse voice, drooling, and burns to head/face are signs suggestive of inhalation injury. Early intubation is critical for these patients as the airway changes rapidly. With inhalation injuries, the upper airway is burned while the lower airway is damaged by inhaled chemicals in the soot and can cause ARDS. Carbon monoxide (CO) and cyanide (CN) poisoning can occur with inhalation injuries. Treatment for CO poisoning is 100% oxygen and possible hyperbarics. Treatment for CN poisoning is cyanocobalamin. References Rehberg S, Maybauer MO, Enkhbaatar P, et al. Pathophysiology, management and treatment of smoke inhalation injury. Expert Rev Respir Med 2009; 3:283. Woodson CL. Diagnosis and treatment of inhalation injury. In: Total Burn Care, 4 ed, Herndon DN (Ed), 2009.

Author: Dylan Luyten, MD Educational Pearls: Most important questions to answer with low potassium are 1. What are their symptoms? 2. Can they take potassium by mouth? Oral repletion is faster, cheaper, and more effective than IV repletion. Give IV potassium when patients have K Most patients who are hypokalemic are hypomagnesemic and require magnesium supplementation. Checking a level is unnecessary. References Ashurst J, Sergent SR, Wagner BJ, Kim J. Evidence-based management of potassium disorders in the emergency department. Emerg Med Pract. 2016 Nov 22;18(Suppl Points & Pearls):S1-S2 Whang R, Flink EB, Dyckner T, et al. Magnesium depletion as a cause of refractory potassium repletion. Arch Intern Med 1985; 145:1686.

Author: Peter Bakes, M.D. Educational Pearls: Epidural hematomas have a characteristic convex appearance on CT while a subdural hematoma will have a concave appearance. Indications for operative intervention for subdural hematoma may include: >5 mm midline shift, over 10 mm in thickness, comatose with ICP >20, or patient neurologic deterioration. References Bullock, M. R. et. al. . Surgical management of acute subdural hematomas. 2006. Neurosurgery, 58(SUPPL. 3). DOI: 10.1227/01.NEU.0000210364.29290.C9. Huang KT, Bi WL, Abd-El-Barr M, Yan SC, Tafel IJ, Dunn IF, Gormley WB. The Neurocritical and Neurosurgical Care of Subdural Hematomas. Neurocrit Care. 2016. 24(2):294-307. doi: 10.1007/s12028-015-0194-x.

Author: Dylan Luyten, MD Educational Pearls: Resuscitative thoracotomies are most commonly used for treatment of cardiac tamponade and to selectively perfuse the brain and heart in setting of hemorrhage control. Resuscitative thoracotomies are indicated in patients with penetrating injuries who lose vitals in the ED or those who had vitals within the last 10 minutes. Do not perform resuscitative thoracotomies on patients who have no signs of life on scene, asystole as their presenting rhythm, or no vitals > 10 minutes. Resuscitative thoracotomies are not indicated in patients with blunt trauma unless vitals are present in ED. Do not perform CPR on trauma patients. References: Karmy-Jones R, Namias N, Coimbra R, et al. (2014).Western Trauma Association critical decisions in trauma: penetrating chest trauma. Journal of Trauma Acute Care Surgery. 77:994. Seamon MJ, Shiroff AM, Franco M, et al. (2009) Emergency department thoracotomy for penetrating injuries of the heart and great vessels: an appraisal of 283 consecutive cases from two urban trauma centers. Journal of Trauma. 67:1250.

Author: Michael Hunt, MD Educational Pearls: Studies have shown that patients with decreasing GCS scores have worse outcomes, however GCS of 4 has worse outcome than GCS 3. Alternative scoring system is the GCS-P score which is GCS score - number of non-reactive pupils. GCS3 50% mortality 70% poor outcome at 6 months; GCS-P of 1 had mortality 74% and poor outcome at about 90% at 6 months. GCS-P score is a better prognostic indicator than GCS score. References: Han J, et al (2014). External validation of the CRASH and IMPACT prognostic models in severe traumatic brain injury. Journal of Neurotrauma. 31(13):1146-52. Maas AI, et al. (2007). Prognosis and clinical trial design in traumatic brain injury: the IMPACT study. Journal of Neurotrauma. 24(2):232-8. The CRASH trial management group, & the CRASH trial collaborators. (2001). The CRASH trial protocol (Corticosteroid randomisation after significant head injury) [ISRCTN74459797]. BMC Emergency Medicine, 1, 1. http://doi.org/10.1186/1471-227X-1-1.

Author: Nick Hatch, MD Educational Pearls: Recent study argues that CHF patients receiving furosemide within 60 minutes of arrival had a lower in-hospital mortality than those receiving it after (2.3% vs. 6.0%, p=0.002). Flaw in study is that there were significant baseline differences between groups. References: Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. JACC 2017. PMID: 28641794